Virginia neglected community-based health services for decades

A warning from the Justice Department that the state faces a lawsuit if it doesn't improve the way it cares for people with intellectual disabilities triggered a flurry of activity this past week, but there shouldn't have been any measure of suprirse: Lawmakers and governors have been told about the problems in the system for almost 50 years.

"Those of us who have been in the field for a long time were applauding" when the Department of Justice report came out, said Chuck Hall, executive director of the Hampton-Newport News Community Services Board. "That is just the latest in a series of reports going back to 1963 that say we have to change the way we allocate funding."

The Department of Justice found that Virginia institutionalized people with intellectual and developmental disabilities when they could have been treated in a less restrictive environment in the community, a violation of the Americans with Disabilities Act.

The state also failed to develop enough community-based services. The state ranks 42nd among states for Medicaid services provided to individuals with intellectual and developmental disabilities, according to the 2010 Case for Inclusion report.

The Justice Department warned that if Virginia didn't make changes, it would file a lawsuit.

The department's investigation focused on treatment of intellectual and developmental disabilities. But a recent report on behavioral health treatment at Eastern State Hospital in James City County by the state Inspector General for Behavioral Health and Development Services pointed out that the same lack of community-based services clogged the pipeline of patients awaiting discharge from the inpatient facility.

For years, the state has poured too many resources into institutions, and too little into community-based care, according to a series of state commissions.

A 1963 commission called for the expansion of community mental health centers and clinics, Hall said.

A 1980 report called for "treatment, training and care in the least restrictive environment" and "urged establishment of services to integrate persons with mental disabilities into the community."

In 1986, a report found that "the difficulties associated with deinstitutionalization could be attributed primarily to a lack of community resources."

In 1998, a commission declared that "Virginians should strive to improve the possibilities for people with mental disabilities to lead independent lives in a community."

Then, in 2007, a gunman with a history of mental illness killed 32 people at Virginia Tech before killing himself. Then-Gov. Timothy M. Kaine set aside $42 million in additional funding to help people with behavioral health problems. But the ensuing recession chipped away nearly all of that infusion, putting the state in the position it's in now, Hall said.

It took the 2007 tragedy, followed by the Department of Justice report, to awaken legislators to what sheriff's offices, county and city officials and community services boards already knew — there wasn't enough money for community services, Hall said.

At Gov. Bob McDonnell's urging, two legislators have introduced bills beefing up Behavioral Health and Developmental Services Trust Fund legislation. Proceeds from selling vacant buildings and land would be used to finance community-based services, including waivers for the intellectually disabled, to shift people from training centers to community-based care. Waivers pay for services in the community rather than in an institution.

The bills also call for a plan to move people from institutions to community-based settings, and for biannual progress reports.

That sets in motion changes to the state treatment system that would outlast McDonnell's four-year term, Hall said.

"This trust fund, if it is kind of like a lock box, if it is protected from the general fund, it will be a permanent example of how state government remains committed to community care," Hall said.

"This administration seems to be very focused on recommending proposals to deal with the issues identified in the Department of Justice report."

Virginia is rare among states for its reliance on state facilities. The state has the 10th largest institutional population in country, said Jamie Liban, executive director of The Arc of Virginia, an advocacy group for people with developmental disabilities. Half the country has closed all institutions or is nearing that goal, she said.

Virginia, on the other hand, is rebuilding institutions, including the recently downsized Eastern State Hospital in James City County.

The state has more than 6,000 people on a waiting list for waivers that would provide community-based services.

But even the waivers the state has issued don't cover all of the services they are allowed to under federal rules, said David Coe, executive director of Colonial Behavioral Health. And the rates the state pays are so low that they don't cover the costs of the services provided.

Virginia has a long way to go.

"What's encouraging here: I hear and see the federal government, the General Assembly and the administration all pretty much on the same page as a result of this," Coe said. "So I have pretty high hopes that we're going to get something done."